Barret esophagus. Etiopathogenesis. Diagnostic and therapeutic aspects

Academy of Sciences of Republic of Moldova, “Nicolae Anestiadi” Surgery Chair, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, The 6th International Medical Congress for Students and Young Doctors, May 12-14, 2016Introduction: Barrett's esophagus is a attractive pathology in gastroenterology for two fundamental reasons. Although its true prevalence is unknown, due largely asymptomatic cases, the widespread introduction of endoscopy allows us to assert that Barret esophagus is a relatively frequent. Esophagus surgery presents particular technical difficulties compared to other organs, because of its position, difficult -to reach and relation with a number of vital organs. Purpose and objectivities: studying the risk factors,the olldness of the pathology,studying subjective and objective clinical signs,endoscopic and radiological analyse. Materials and methods: This research is based on analys of 154 patiens with gastro-esophagian reflux disease and barrett esophagus,examined in Public Healthcare Institution,Republican Center of Medical Diagnosis,during 2014 year.The patients were divided into 2 groups:first with 140 (90%)patients with gastro-esophagian reflux disease and the second that included 14 (10%)patients with Barret esophagus.Results: The clinical examination included 154 patiants to which was revealed: GERD,esopgagitis and Barret esophagus.The male sex was predominant and represented 104(67.5%)patients and female sex represented 50(32.4%) patients. The clinical signs was determined by heartburn that was revealed at 130 patients(92%) from first group and 2 patients(14%) from second group.The second sign most commonly found was beltching that was revealed at 20 patients from first group(14%) and 9 cases from second group(64%).The endoscopic examination was the basic examination of all patients.At 103 patients from all(70%) was found evident signs of incapacity of inferior sphincter of esophagus,and namely the biant cardia,and its opening to a light air blast,but at 43 patients was not found these signs,despite of presence of clinical and endoscopic sign of esophagitis reflux.At 48 patients(32.9%),endoscopy set nonconfluent island hyperemia at lower region of the esophagus,which corresponded to the first level of reflux esophagities after Savary Miller.At 57patients(39%) was revealed hyperemia and confluent mucosal erosions that corresponded to the second level of reflux esophagities after Savary-Miller. The third level after Savary- Miller was found at 29 patients(19%) and the forth level at 12 patients (8%). The radiological examinations was performed at 106 patients from which 104 patients was with gastro-esophagian reflux disease,and 2 patients with Barret esophagus.At patiens with GERD-78 cases was found with radiological signs of reflux,but at 24 patients was not found any signs. Conclusions: Barret esophagus was found mostly at male sex,the averrage age being 45- 50years.The most common clinical signs was heartburn 89% cases,followed by epigastric pain and beltching-78%. At 103patients from all(70%) was found evident signs of incapacity of inferior sphincter of esophagus,and namely the biant cardia,and its opening to a light air blast,but at 43 patients was not found these signs,despite of presence of clinical and endoscopic sign of esophagitis reflux

Rare complication of surgical intervention for acute limb ischemia: a case report

Department of General Surgery and Semiology no. 3 Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova, The 8th International Medical Congress for Students and Young Doctors, September 24-26, 2020Background. Complications of balloon catheter embolectomy for acute arterial occlusion are extremely rare and there is a lack of clear recommendations for its management. This report describes a case of peroneal artery (PA) pseudoaneurysm that developed after lower limb thrombembolectomy using Fogarty balloon catheter and was successfully treated by transluminal coil embolization. Case report. A 84-year-old female patient presented to the emergency department 5 hours after sudden onset of pain in the right lower extremity. She had a known history chronic atrial fibrillation, being on ongoing treatment with warfarin. Clinical examination discovered absent popliteal and plantar pulses and typical signs of acute limb ischemia. The hand-held Doppler revealed inaudible arterial and audible venous signals at the level of the right foot. Under spinal anesthesia the right common femoral artery was dissected and a 4F Fogarty embolectomy catheter was easily advanced down to the tibial arteries. The embolectomy was performed successfully with recovering of plantar pulses postoperatively. Four hours later clinical manifestations of the compartment syndrome were observed and “2-incision 4-compartments” fasciotomy was performed. Prolonged bleeding from fasciotomy wounds was noted after surgery, considered being caused by systemic heparinization. After transfusion of 3 units of red blood cells, one litter of plasma and several reapplications of bandage bleeding was controlled. After 3 days the fasciotomy wounds were sutured. Patient was discharged at 5-th postoperative day, anticoagulated with 20 mg of rivaroxaban. Eighteen days after discharge, she returned to the hospital with complaints to severe, permanent pain in right leg. Clinical examination noted extensive pulsation of the right calf with audible systolic bruit. Duplex ultrasound suggested a large pseudoaneurysm of the PA. Digital subtraction angiography confirmed a 55 mm large sacular pseudoaneurysm of the PA and patent tibial run-off. A microcatheter (Progreat®, Terumo) was percutaneously inserted into the right PA via ipsilateral antegrade femoral approach. Two detachable coils (Azur®, Terumo) were deployed distally to the aneurysm and 5 coils were released in the proximal PA and aneurysm sac. The complete occlusion of pseudoaneurysm was achieved. Postoperatively patient becomes symptom free and ultrasound confirmed absence of flow in pseudoaneurysm. Conclusions. Apart from the rarity of iatrogenic pseudoaneurysm of PA, this case highlights the risk of severe complications associated with relative simple procedure of balloon catheterembolectomy. Vascular imaging should be performed if patient demonstrates unusual postoperative evolution

Современные тенденции в лечении острой ишемии конечностей: обзор литературы

Rezumat. Ischemia acută a extremităților (IAE) reprezintă o urgență clinică care se poate solda cu posibila pierdere a membrelor și care poate avea consecințe ce pun în pericol viața. IAE se caracterizează printr-o scădere bruscă a perfuziei membrelor și este definită ca debutul simptomelor mai puțin de 14 zile. Îmbătrânirea populației, efect prezent și în Republica Moldova, crește prevalența IAE. Cele două etiologii principale ale IAE sunt embolia arterială și tromboza in situ a unei artere aterosclerotice. IAE este una dintre cele mai frecvente cauze de amputație majoră, afectând aproximativ 1,5 la 10.000 de persoane anual. Sindromul de ischemie-reperfuzie însoțit de insuficiența renală acută, hiperkaliemia și acidoza metabolică sunt consecințe sistemice potențiale ale IAE netratate și adesea pun viața în pericol. Diagnosticul imediat, evaluarea precisă și intervenția de revascularizare urgentă sunt cruciale pentru salvarea membrului și pentru a preveni complicații sistemice severe. Întârzierea diagnosticului și a tratamentului poate duce la leziuni ischemice ireversibile.Summary. Acute limb ischemia (ALI) is a clinical emergency with possible limb loss and life-threatening consequences. ALI is characterized by a sudden decrease in limb perfusion. It is defined as duration of symptoms for less than 14 days. The aging of the population, an effect also present in the Republic of Moldova, increases the prevalence of ALI. The two main etiologies of ALI are arterial embolism and thrombosis of an atherosclerotic artery. It is one of the most common causes of major amputation, affecting approximately 1.5 in 10,000 people annually. Ischemia-reperfusion syndrome accompanied with acute renal failure, hyperkalemia, and metabolic acidosis are potential systemic consequences of untreated ALI. Prompt diagnosis, accurate assessment, and urgent intervention for revascularization are crucial for limb salvage and prevention of severe systemic complications. Delay in diagnosis and therapy can lead to irreversible ischemia.Резюме. Острая ишемия конечностей (ОИК) является неотложным клиническим состоянием с возможной потерей конечности и опасностью для жизни. ОИК характеризуется внезапным снижением перфузии конечностей и определяется как продолжительность симптомов менее 14 дней. Тенденция к старению населения, которая также наблюдается в Республике Молдова, обуславливает рост числа случаев ОИК. Двумя основными причинами ОИК являются артериальная эмболия и тромбоз артерии, поражённой атеросклерозом. ОИК – одна из основных причин ампутаций, выполняемых ежегодно с частотой примерно 1,5 случая на 10.000 человек. Синдром ишемии-реперфузии, сопровождающийся острой почечной недостаточностью, гиперкалиемией и метаболическим ацидозом, является потенциальными системным проявлением запущенной ОИК. Своевременная и точная диагностика, срочное реваскуляризирующее вмешательство имеют решающее значение для спасения конечности и предотвращения тяжёлых системных осложнений. Задержка в диагностике и лечении может привести к необратимой ишемии

New approaches for diagnosis of acute non-traumatic ischemia of the extremities: literature review

Catedra chirurgie generală - semiologie nr. 3, Clinica chirurgie vasculară, Universitatea de Stat de Medicină și Farmacie „Nicolae Testemițanu”, Chișinău, Republica Moldova, Institutul de Medicină Urgentă, Secția chirurgie vasculară, Chișinău, Republica MoldovaObiective. Scopul lucrării a fost de a analiza datele și dovezile din sursele existente de literatură, cu privire la diagnosticul ischemiei acute nontraumatice a extremităților. Materiale și metode. Au fost analizate publicații științifice, ce prezintă dovezi privind diagnosticul ischemiei acute non-traumatice a extremităților. În calitate de surse de căutare au fost utilizate bazele de date Google Scholar și PubMed. Cuvintele cheie utilizate în căutare au fost “diagnosis” , “nontraumatic”, “acute limb ischemia”. Rezultate. Au fost identificate 25 publicații științifice ce reflecta dovezi actuale referitor la diagnosticul ischemiei acute non-traumatice a extremităților. Concluzii. Diagnosticul ischemiei acute a extremităților, precum și evaluarea severității acesteia, la momentul actual, rămâne a fi bazat pe examinarea clinică minuțioasă a pacientului. Implementarea în practica clinică a unor tehnici suplimentare (examen CW-Doppler, termografie) poate contribui la obiectivizarea semnelor ischemiei și reducerea ratei erorilor diagnostice. Metode de imagistică vasculară non-invazivă și, în primul rând, ultrasonografia duplex, oferă informații cruciale pentru selectarea metodelor de revascularizare, însă impactul real și eficiența acestora necesită evaluarea în mai multe studii prospective, realizate în condițiile sistemelor medicale diferite. Determinarea corelațiilor dintre nivelul biomarcherilor inflamației și ischemiei tisulare cu rezultatele tratamentului ischemiei acute a extremităților reprezintă un domeniu de perspectivă pentru cercetări științifice.Objectives. The aim of the study was to analyze evidence based data from existing literature sources, on the diagnosis of acute non-traumatic ischemia of the extremities. Material and methods. Google Scholar and PubMed search engines were used to find evidence based data for diagnosis of acute non-traumatic ischemia of the extremities. The following keywords were used for search: "diagnosis”, “non-traumatic”, “acute limb ischemia” Results. There were identified 25 scientific publications that reflect current evidence regarding the diagnosis of the diagnosis of acute non-traumatic ischemia of the extremities. Conclusion. The diagnosis of acute limb ischemia, as well as the assessment of its severity at present, remains to be based on the clinical examination of the patient. The implementation of additional techniques in clinical practice (CW-Doppler examination, thermography) can help to objectify the signs of ischemia and reduce the rate of diagnostic errors. Non-invasive vascular imaging methods, and primarily duplex ultrasound, provide crucial information for the selection of revascularization methods, but their real impact and effectiveness require evaluation in several prospective studies conducted in different medical systems. Determining the correlations between the level of biomarkers of inflammation and tissue ischemia with the results of acute limb ischemia treatment is a field of perspective for scientific research

Surgical treatment for chronic postembolic occlusion of the femoropopliteal arteries

Introduction. Acute limb ischemia (ALI) is a condition that threatens not only the affected extremities but even the patient's life and therefore requires prompt intervention. The embolism is listed among the main causes of ALI, while emergency open surgical thromboembolectomy is still the standard approach to prevent limb loss. However, some patients tolerate the episode of ALI and are hospitalized afterwards (>14 days from onset) with symptoms of chronic limb ischemia. Aim of study. The aim of our study was to evaluate the outcomes of surgical management in cases of chronic limb ischemia caused by embolic occlusion of the femoropopliteal arteries. Methods and materials. The study was conducted at the Vascular Surgery Clinic, Institute of Emergency Medicine (Chisinau, Republic of Moldova), and included patients hospitalized between July 2019 and January 2022. A case series comprises 19 patients; aged between 38 and 88 years, median – 70 (25%-75% IQR 63-78) years. There were 10 (52.63%) men and 9 (47.36%) female patients; the left lower limb was affected in 13 (68.42%) cases. All patients noticed an acute onset of ischemic symptoms 15 to 182 days before admission, median – 20 (25%-75% IQR 15-30) days; while medical history did not reveal preexisting peripheral arterial disease. Paroxysmal (n=9) or tachysystole (n=10) forms of atrial fibrillation have been diagnosed in all cases. In accordance with Fontaine classification of chronic limb ischemia there were 4 (21.05%) cases suitable for stage II, 12 (63.15%) limbs with stage III and other 3 (15.78%) – with stage IV. Isolated occlusion of femoropopliteal arteries along with absence of additional significant lesions suggestive for peripheral arterial disease has been confirmed by imaging: computed tomography angiography (n=9), duplex ultrasound (n=9) and digital subtraction angiography (n=5). Results. All patients underwent surgical treatment, either under spinal (n=17) or general (n=2) anesthesia. Open thromboembolectomy was performed in 16 (84.21%) cases, in two patients being completed with vein patch angioplasty. In 2 (10.52%) cases distal femoropopliteal bypass with autologous vein was required, and in one (5.26%) patient vein graft interposition at the popliteal level was practiced. In 3 patients who underwent thromboembolectomy early reocclusion of femoropopliteal arteries was diagnosed. Restoration of blood flow was achieved through reconstructive vascular surgery: femoropopliteal/tibial bypass (n=2) or graft interposition (n=1). During the study period no cases of postoperative mortality were recorded, while the rate of major limb amputations was 10.52% (2 cases). Conclusion. Open thromboembolectomy provides clinically acceptable results in patients with chronic postembolic occlusion of the femoropopliteal arteries. In cases of technical failure or early vessel reocclusion, reconstructive vascular operations remain a reliable option for restoring the arterial patency

Primary hydatid cyst of skeletal muscle: a case report

Department of surgery and semiology no.3, Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of MoldovaBackground. Hydatid cyst, also called hydatidosis, is caused by Echinococcus granulosus. It is still a major health problem in many parts of the world with 2-3 million cases confirmed each year. Most of these cases involve liver (50-70%) and lungs (20-30%), but some of them have rare locations, such as skeletal muscles (0.7-5%). The absence of specific clinical signs and symptoms makes it difficult to establish a diagnosis, while first signs may appear as neurovascular lesions due to compression. The most useful method of diagnosis is ultrasound with high sensitivity (93-98%), followed by CT and MRI. There are two types of treatment: open surgery and percutaneous drainage, both associated with Albendazole and Mebendazole or Albendazole and Praziquantel administration

Rolul predictiv al raportului neutrofile-limfocite în tratamentul ischemiei al extremităților

Introducere. Rolul biomarcherilor în prognozarea evoluției și rezultatelor tratamentului în ischemiei acute a extremităților IAE este studiat insuficient. Astfel indicii de laborator ce reflectă severitatea răspunsului inflamator sistemic pot fi utile în estimarea riscului amputației și decesului. Scop. Scopul studiului a fost analiza valorii predictive al raportului neutrofile-limfocite RNL în prognozarea mortalității și riscului de amputație majoră la pacienții cu IAE. Materiale și metode. Toți pacienții consecutiv cu IAE spitalizați în Institutului de Medicina Urgentă și supuși tratamentului de revascularizare în mod urgent în perioada 2019 - 2022 au fost înrolați prospectiv. Indicatorul RNL a fost derivat din analiza generală a sângelui, prelevată preoperator. Rata mortalității și amputațiilor majore a fost evaluată pe durata spitalizării la o lună. Rezultate. În total în studiu au fost incluși 157 pacienți. Mediana vârstei pacienților a constituit 71 ani. Sexul masculin a prevalat – 97(61.8%) pacienți. Gradul de IAE conform clasificării Rutherford: gradul I – 10(6.3%) cazuri, gradul IIA – 57 (36.3%) cazuri, gradul IIB – 90(57.3%) cazuri. În lotul general mediana NLR a fost 6.9 (25-75% IQR 5.3-7.6). Valoarea medie RNL a fost semnificativ mai mare la bolnavii cu IAE gradul IIB – 7.7 (95% CI 7.9 - 9.9) - vs gradul IIA – 5.0 (95% CI 4.2-6.4), p<0.0001. La interval de 30 zile rata mortalității a constituit – 17.8%, iar rata amputațiilor – 10.1%. Aria sub curbă ROC pentru RNL a fost 0.713, iar valoarea predictivă optimă a constituit 5.8. Concluzii. Indice RNL este un test informativ simplu și disponibil pe scară largă care poate contribui la luarea deciziilor tactice argumentate în tratamentul bolnavilor cu IAE

THE ROLE OF FASCIOTOMY FOR COMPARTMENT SYNDROME IN PATIENTS WITH ACUTE LIMB ISCHEMIA

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaIntroducere. Sindromul de compartiment (SC) este o complicație tipică a ischemiei acute a extremităților (IAE) cu o incidență de 20-30%. Fasciotomia este singura opțiune curativă eficientă pentru SC. Scop. Evaluarea factorilor asociați cu dezvoltarea SC și a impactului fasciotomiei precoce asupra rezultatelor revascularizării. Metode: În perioada 2019-2021 au fost înrolați prospectiv și evaluați ulterior la termenul de 3 luni 142 de pacienți consecutivi supuși revascularizării pentru IAE. SC a fost suspectat clinic și confirmat prin măsurarea presiunii intracompartimentare (>30 mm Hg) sau de perfuzie ( 10°C: 16 (69,5%) în grupul cu SC vs. 30 (25,2%) în lotul de control (p 30 mm Hg) or perfusion ( 10°C: 16 (69.5%) in group with CS vs. 30 (25.2%) in control one (p < 0.0001). Temperature gradient was independently associated with presence of CS in multivariable analysis: OR 9.8 (1.1-29.4). During the follow-up in entire cohort, major amputation was registered in 21.1% cases and death – in 17.6%, without significant difference between compared groups. Conclusion. Early diagnosis and treatment of compartment syndrome can mitigate its negative impact upon the outcomes of treatment of acute limb ischemia. Forehead-to-foot temperature gradient can be used as an adjunct for clinical diagnosis of compartment syndrome

ISCHEMIA ACUTĂ PERIFERICĂ ASOCIATĂ INFECȚIEI SARS-CoV-2: EXPERIENȚA DE DIAGNOSTIC ȘI TRATAMENT

Studiul a prevăzut evaluarea rezultatelor tratamentului ischemiei acute (IA) a extremităților la pacienții cu infecție cu coronavirus de tip nou (COVID-19). Lotul a inclus 62 pacienți; 67 extremități: superioare - 19 (28,3%), inferioare - 48 (71,6%). Repartizarea cazurilor în funcție de gradul IA (Rutherford): I - 7 (10,4%), IIA - 10 (14,9%), IIB - 34 (50,7%), III - 16 (23,8%). COVID-19 s-a confirmat prin testul polymerase chain reaction , la 45 (72,5%) pacienți fiind documentată afectarea pulmonară. Tratamentului chirurgical au fost supuși 50 (80,6%) pacienți; 52 membre. Rata amputațiilor pe durata spitalizării (9,4±9 zile) - 19,4%; rata decesului - 43,5%, fiind influențată semnificativ de prezența sau absența afectării pulmonare - 55,5% vs. 11,7% (P=0,002; testul χ²). Potențial predictiv al mortalității au manifestat biomarkerii: proteina C reactivă/albumina, trombocite/limfocite, fibrinogen/albumina. Către follow-upul de 21 (25%-75%IQR 19-28) luni supraviețuirea generală și fără amputații: 56,4% și 57,1%, corespunzător

Rolul fasciotomiei în sindromul de compartiment la pacienții cu ischemie acută a extremităților

Introduction. Compartment syndrome (CS) is a typical complication of acute limb ischemia (ALI) with an incidence of 20-30%. Fasciotomy is a single effective treatment for CS. Aim. Evaluation of factors associated with development of CS as well as of impact of early fasciotomy upon the results of revascularization. Methods. During 2019-2021 periods 142 consecutive patients supposed to revascularization for ALI were prospectively enrolled and followed-up for 3 months. CS was suspected clinically and confirmed by measuring intra-compartmental (> 30 mm Hg) or perfusion (< 20 mm Hg) pressure. In all cases, the forehead-to-foot temperature gradient (ΔT) was determined. In all patients with CS four-compartment fasciotomy was performed simultaneously with revascularization. Results. CS was diagnosed and treated in 23 patients. Patients with CS were more frequently diagnosed with grade IIB ALI – 20 (86.9%) vs. 63 (52.9%) cases in patients without CS (p < 0.01) and had higher level of myoglobin: 443.2 ± 345 vs. 169.2 ± 284 ng/ml (p<0.05). The most significant difference was found in the rate of limbs with ΔT > 10°C: 16 (69.5%) in group with CS vs. 30 (25.2%) in control one (p < 0.0001). Temperature gradient was independently associated with presence of CS in multivariable analysis: OR 9.8 (1.1-29.4). During the follow-up in entire cohort, major amputation was registered in 21.1% cases and death – in 17.6%, without significant difference between compared groups. Conclusion. Early diagnosis and treatment of compartment syndrome can mitigate its negative impact upon the outcomes of treatment of acute limb ischemia. Forehead-to-foot temperature gradient can be used as an adjunct for clinical diagnosis of compartment syndrome.Introducere. Sindromul de compartiment (SC) este o complicație tipică a ischemiei acute a extremităților (IAE) cu o incidență de 20-30%. Fasciotomia este singura opțiune curativă eficientă pentru SC. Scop. Evaluarea factorilor asociați cu dezvoltarea SC și a impactului fasciotomiei precoce asupra rezultatelor revascularizării. Metode: În perioada 2019-2021 au fost înrolați prospectiv și evaluați ulterior la termenul de 3 luni 142 de pacienți consecutivi supuși revascularizării pentru IAE. SC a fost suspectat clinic și confirmat prin măsurarea presiunii intracompartimentare (>30 mm Hg) sau de perfuzie (<20 mm Hg). În toate cazurile s-a determinat gradientul de temperatură frunte-plantă (ΔT). La toți pacienții cu SC concomitent cu revascularizarea a fost efectuată fasciotomia celor patru compartimente ale gambei. Rezultate. SC a fost stabilit și tratat la 23 de pacienți. Bolnavii cu SC au fost diagnosticați mai frecvent cu IAE de gradul IIB – 20 (86,9%) vs. 63 (52,9%) cazuri la pacienții fără SC (p<0,01) și au avut un nivel mai ridicat de mioglobină: 443,2 ± 345 vs. 169,2 ± 284 ng/ml (p < 0,05). Cea mai semnificativă diferență a fost identificată între ratele membrelor cu ΔT > 10°C: 16 (69,5%) în grupul cu SC vs. 30 (25,2%) în lotul de control (p < 0,0001). Gradientul de temperatură s-a asociat independent cu prezența SC în cadrul analizei multivariabile: OR 9,8 (1,1-29,4). În întreaga cohortă la intervalul de follow-up amputația majoră a fost înregistrată în 21,1% cazuri, iar decesul – în 17,6%; fără diferențe semnificative între grupurile comparate. Concluzie. Diagnosticul și tratamentul precoce al sindromului de compartiment poate atenua impactul negativ al acestuia asupra rezultatelor tratamentului ischemiei acute a extremităților. Gradientul de temperatură frunte-plantă poate fi utilizat ca indice adjuvant pentru diagnosticul clinic al SC